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2014 Bridging the Gap Colorado

Application 

 APPLICANT INFORMATION INCOMPLETE SUBMISSIONS WILL NOT BE ACCEPTED

In order to renew your eligibility for Bridging the Gap Colorado, this form must be filled out completely. Fill out all

information you know and mail or fax it to the Colorado ADAP using the information at the end of this packet.Please indicate what parts of Medicare you know you receive.

By signing below, I attest that the above information is, to the best of my knowledge, true and accurate. In addition

to the consent granted to ADAP by the release of information included in the ADAP recertification, I grant Bridgingthe Gap Colorado my permission to correspond with the Centers for Medicare and Medicaid Services (CMS) and my

Part D Plan in order to obtain information that they may need in order to coordinate pharmaceutical benefits

through Medicare. I grant Bridging the Gap Colorado permission to enroll me in “Extra Help” for Part D if it is

determined that I qualify.

 Name: ____________________________ Signature:___________________________ Date:________ 

NAME OF BENEFICIARY (your name):

MEDICARE CLAIM NUMBER: SEX:

IS ENTITLED TO: (PLEASE CHECK ALL THATAPPLY):

HOSPITAL (PART A)

MEDICAL (PART B)

EFFECTIVE DATES:

DATE OF BIRTH (MM/DD/YYYY):

 _______ / _______ / __________ CURRENT ZIP CODE:

If this is your first time applying for

Bridging the Gap Colorado, please check

here:

LOW-INCOME SUBSIDY INFORMATION:

(If you make more than $1,396 a month, please skip to PREMIUM PAYMENT INFORMATION)

Are you currently receiving “Extra Help” from Medicare for your Part D costs? (Check One):

Yes / No / I Don’t KnowIf No or Don’t Know, please complete the following information. This information will not be used to determine eligibility for

ADAP’s programs but instead will be used as a guide to determine if you may qualify for any financial assistance programs

provided by Social Security or Medicaid. ADAP reserves the right to complete an application for Low-Income Subsidy on your

behalf. You may receive information about Medicare Savings Programs in the mail.

SOCIAL SECURITY INCOME: Do you own any property in addition to the home that you

live in and/or any vehicles you may own? (do not count yo

house you live in, vehicles or burial plots):OTHER INCOME:

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PREMIUM PAYMENT INFORMATION 

If you do not have a plan premium or are paying the premium

yourself, DO NOT complete this section

If you have a premium payment you would like BTGC to pay, but don’t have a copy of your 2014 invoice or

payment coupon book available yet, please put this portion in a place you will remember it (for example, on your

refrigerator) for when you receive your 2014 Part D coupon book or premium invoice. If you have already receivedyour invoice or coupon book, please read the agreement below, sign and return this form with the applicable

invoice/coupon to the Colorado ADAP using the information below. BTGC will pay up to $80.00/month for your Part

D plan premium.

If you received a coupon book, please affix ONE COUPON in the space provided below using tape and keep the

remaining coupon book for your records. If you have an invoice, please make sure your name is visible on the

invoice and staple it to this page.

Any portion of the premium that applies to dental, vision or hearing coverage, or exceeds the $80.00 limit will be

your responsibility to pay. BTGC will not be held liable for any loss of coverage that results from non-payment onyour behalf or for any plan for which a premium invoice was not submitted to the Colorado ADAP for payment. It is

your responsibility to notify the Colorado ADAP of any correspondence you may receive from your Part D plan

regarding changes to coverage, late payments or possible discontinuation. You are also required to surrender any

refund checks given to you by your Part D plan for any services paid by the Colorado ADAP for premiums or co-pays

as that money is the sole property of the Colorado ADAP. Failure to surrender checks in a timely manner will result

in discontinuation of coverage until the funds have been returned to the Colorado ADAP. By signing below, you

agree to these terms and conditions. Please provide your phone number in case we need to reach you for

questions.

Name:_________________________ Signature:________________________ Phone Number__________________

No premium shall be paid on your behalf until this signed document is received with a premium invoice or Part D coupon. Mail

or fax this completed form with a copy of your premium invoice or coupon book to the information below.

Bridging the Gap Colorado

C/O Colorado ADAP

A3-3800

4300 Cherry Creek South Dr.

Denver, CO 80246

(303) 692-2716 | Fax: (303) 691-7736 

AFFIX COUPON

HERE